AAP eBooks

Opioid Addiction

By American Academy of Pediatrics

The opioid crisis has become far more serious than some of the other epidemics the country has faced. This collection of timely AAP journal articles, blog posts, and policy explores the risks and possible solutions.

https://shop.aap.org/pediatric-collections-opioid-epidemic-paperback/

  1. Page 1
  2. Page 5
    Abstract
    Address correspondence to Gary A. Smith, MD, DrPH, Director, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: gary.smith@nationwidechildrens.org

    OBJECTIVES This study analyzes and compares exposures to prescription opioids among children and adolescents younger than 20 years old in the United States.

    METHODS Data from the National Poison Data System for 2000 through 2015 were analyzed.

    RESULTS Poison control centers received reports of 188 468 prescription opioid exposures among children aged <20 years old from 2000 through 2015. The annual number and rate of exposures increased early in the study period, but declined after 2009, except for buprenorphine exposures, which increased during the last 3 study years. Hydrocodone accounted for the largest proportion of exposures (28.7%), and 47.1% of children exposed to buprenorphine were admitted to a health care facility (HCF). The odds of being admitted to an HCF were higher for teenagers than for children aged 0 to 5 years (odds ratio [OR]: 2.86; 95% confidence interval [CI]: 2.78–2.94) or children aged 6 to 12 years (OR: 6.62; 95% CI: 6.06–7.02). Teenagers also had greater odds of serious medical outcomes than did children aged 0 to 5 years (OR: 3.03; 95% CI: 2.92–3.15) or children aged 6 to 12 years (OR: 4.59; 95% CI: 4.21–5.00). The rate of prescription opioid–related suspected suicides among teenagers increased by 52.7% during the study period.

    CONCLUSIONS Prescription opioid–related HCF admissions and serious medical outcomes were higher among teenagers. Contrary to trends for other prescription opioids, exposures to buprenorphine have increased in recent years; children aged 0 to 5 years accounted for almost 90% of buprenorphine exposures. These findings indicate that additional prevention efforts are needed.

  3. Page 16
    Abstract
    Address correspondence to Sean Esteban McCabe, PhD, 204 South State St, Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109. E-mail: plius@umich.edu

    OBJECTIVES Most US studies of national trends in medical and nonmedical use of prescription opioids have focused on adults. Given the limited understanding in these trends among adolescents, we examine national trends in the medical and nonmedical use of prescription opioids among high school seniors between 1976 and 2015.

    METHODS The data used for the study come from the Monitoring the Future study of adolescents. Forty cohorts of nationally representative samples of high school seniors (modal age 18) were used to examine self-reported medical and nonmedical use of prescription opioids.

    RESULTS Lifetime prevalence of medical use of prescription opioids peaked in both 1989 and 2002 and remained stable until a recent decline from 2013 through 2015. Lifetime nonmedical use of prescription opioids was less prevalent and highly correlated with medical use of prescription opioids over this 40-year period. Adolescents who reported both medical and nonmedical use of prescription opioids were more likely to indicate medical use of prescription opioids before initiating nonmedical use.

    CONCLUSIONS Prescription opioid exposure is common among US adolescents. Long-term trends indicate that one-fourth of high school seniors self-reported medical or nonmedical use of prescription opioids. Medical and nonmedical use of prescription opioids has declined recently and remained highly correlated over the past 4 decades. Sociodemographic differences and risky patterns involving medical and nonmedical use of prescription opioids should be taken into consideration in clinical practice to improve opioid analgesic prescribing and reduce adverse consequences associated with prescription opioid use among adolescents.

  4. Page 30
    Abstract
    Address correspondence to Eileen M. McDonald, MS, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 731, Baltimore, MD 21205. E-mail: emcdona1@jhu.edu

    OBJECTIVES To describe safe storage practices and beliefs among adults who have used a prescription opioid pain reliever (OPR) in the past year; to compare practices and beliefs among those living with younger (<7 years) versus older children (7–17 years).

    METHODS A survey was administered to a nationally representative sample of adults reporting OPR use in the previous 12 months and who had children <18 years old living with them. We used Health Belief Model–derived items to measure beliefs. Safe storage was defined as locked or latched for younger children and as locked for older children. Regression models examined the association between beliefs and safe storage practices.

    RESULTS Among 681 adults who completed our survey and reported having children in their home, safe storage was reported by 32.6% (95% confidence interval [CI], 21.4–43.8) of those with only young children, 11.7% (95% CI, 7.2–16.2) among those with only older children, and 29.0% (95% CI, 18.3–39.8) among those with children in both age groups. Among those asked to answer survey questions thinking about only their oldest child, the odds of reporting safe storage decreased by half as perceived barriers increased (0.505; 95% CI, 0.369–0.692), increased twofold as efficacy increased (2.112; 95% CI, 1.390–3.210), and increased (1.728; 95% CI, 1.374–2.174) as worry increased.

    CONCLUSIONS OPRs are stored unsafely in many households with children. Educational messages should address perceived barriers related to safe storage while emphasizing how it may reduce OPR access among children.

  5. Page 40
    Abstract
    Address correspondence to Yaron Finkelstein, MD, FACMT, Professor of Pediatrics, Pharmacology and Toxicology, University of Toronto, Divisions of Emergency Medicine and Clinical Pharmacology and Toxicology, 555 University Ave, Toronto, ON M5G 1X8, Canada. E-mail: yaron.finkelstein@sickkids.ca

    BACKGROUND AND OBJECTIVE Over the past 20 years, the prescribing of opioids has increased dramatically in North America, with parallel increases in opioid addiction, overdose, and associated deaths. We examined whether young children of women prescribed opioids were at increased risk of opioid overdose.

    METHODS We conducted a population-based, nested case control study in Ontario, Canada, between 2002 and 2015. We identified children aged ≤10 years, whose mothers received publicly funded prescriptions for an opioid or a nonsteroidal antiinflammatory drug (comparator analgesic) in the preceding year. Cases were children who presented to hospital for or died of opioid overdose. Each case was matched with 4 controls with no opioid overdose. The primary outcome was the risk of opioid overdose.

    RESULTS We identified 103 children who presented to the hospital with opioid overdose and matched them with 412 controls. Half of the children with opioid overdose were <2 years old. Compared with controls, children with an opioid overdose were far more likely to have a mother who received a prescription opioid (unadjusted odds ratio, 2.41; 95% confidence interval, 1.68–3.45) and who was prescribed antidepressants. The most commonly implicated overdose opioids were codeine (53.4%), oxycodone (32.0%), and methadone (15.5%).

    CONCLUSIONS Young children of mothers prescribed opioids are at a markedly increased risk of overdose. Physicians, pharmacists, and parents should take measures to mitigate the risk of opioid-related harm to children, such as prescribing smaller quantities, emphasizing the importance of secure medication storage, and the prompt disposal of unused opioids.

  6. Page 49
    Abstract
    Address correspondence to Richard Miech, PhD, Institute for Social Research, University of Michigan, 426 Thompson St, Ann Arbor, MI 48106-1248. E-mail ramiech@umich.edu

    BACKGROUND AND OBJECTIVE Legitimate opioid use is associated with an increased risk of long-term opioid use and possibly misuse in adults. The objective of this study was to estimate the risk of future opioid misuse among adolescents who have not yet graduated from high school.

    METHODS Prospective, panel data come from the Monitoring the Future study. The analysis uses a nationally representative sample of 6220 individuals surveyed in school in 12th grade and then followed up through age 23. Analyses are stratified by predicted future opioid misuse as measured in 12th grade on the basis of known risk factors. The main outcome is nonmedical use of a prescription opioid at ages 19 to 23. Predictors include use of a legitimate prescription by 12th grade, as well as baseline history of drug use and baseline attitudes toward illegal drug use.

    RESULTS Legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school. This association is concentrated among individuals who have little to no history of drug use and, as well, strong disapproval of illegal drug use at baseline.

    CONCLUSIONS Use of prescribed opioids before the 12th grade is independently associated with future opioid misuse among patients with little drug experience and who disapprove of illegal drug use. Clinic-based education and prevention efforts have substantial potential to reduce future opioid misuse among these individuals, who begin opioid use with strong attitudes against illegal drug use.

  7. Page 60
    Abstract
    Address correspondence to Jennifer F. Waljee, MD, MPH, MS, Department of Surgery, UMH Plastic Surgery, 1500 E Medical Center Dr, 2130 Taubman Center, Ann Arbor, MI 48109-5340. E-mail: filip@med.umich.edu

    BACKGROUND Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients.

    METHODS We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure.

    RESULTS Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%–15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00–1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01–5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill.

    CONCLUSIONS Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.

  8. Page 71
    Abstract
    Address correspondence to Stephen W. Patrick, MD, MPH, MS, FAAP. E-mail: stephen.patrick@vanderbilt.edu

    The use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical, including the following: a focus on preventing unintended pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge and informed consent of maternal drug testing and reporting practices; improved access to comprehensive obstetric care, including opioid-replacement therapy; gender-specific substance use treatment programs; and improved funding for social services and child welfare systems. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool (December 2016).

  9. Page 78
    Abstract
    Address correspondence to Stephen W. Patrick, MD, MPH, MS, Monroe Carell Jr Children’s Hospital at Vanderbilt, Mildred Stahlman Division of Neonatology, 11111 Doctor’s Office Tower, 2200 Children’s Way, Nashville, TN 37232-9544. E-mail: stephen.patrick@vanderbilt.edu

    BACKGROUND AND OBJECTIVES Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS).

    METHODS We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics.

    RESULTS Of 112 029 pregnant women, 31 354 (28%) filled ≥1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67–2.60]) were associated with greater risk of developing NAS.

    CONCLUSIONS Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS.

  10. Page 90
    Abstract
    Address correspondence to Rachel Thienprayoon, MD, MSCS, Pediatric Palliative and Comfort Care Team, Dept of Anesthesiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML-2001, Cincinnati, OH 45229-3039. E-mail: rachel. thienprayoon@cchmc.org

    BACKGROUND The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children’s Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse.

    METHODS The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: “In patients who present for follow up with PACT, we will use the “opioid bundle” to increase risk stratification for opioid misuse from 0% to 90% over 5 months.” The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members.

    RESULTS Since implementing the new system, we have increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results have been sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk.

    CONCLUSIONS A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse.

  11. Page 105
    Abstract

    Opioid use disorder is a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction.

  12. Page 109
    Abstract

    Opioids are often prescribed to children for pain relief related to procedures, acute injuries, and chronic conditions. Round-the-clock dosing of opioids can produce opioid dependence within 5 days. According to a 2001 Consensus Paper from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, dependence is defined as “a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” Although the experience of many children undergoing iatrogenically induced withdrawal may be mild or goes unreported, there is currently no guidance for recognition or management of withdrawal for this population. Guidance on this subject is available only for adults and primarily for adults with substance use disorders. The guideline will summarize existing literature and provide readers with information currently not available in any single source specific for this vulnerable pediatric population.

  13. Page 113
    Abstract
    Address correspondence to Emily C. Atwood, MD, Children’s National Medical Center, Graduate Medical Education Office, 111 Michigan Ave NW, Washington, DC 20010. E-mail: ecatwood2@childrensnational.org

    BACKGROUND AND OBJECTIVES Although the incidence of neonatal abstinence syndrome (NAS) in the United States quintupled between 2000 and 2012, little is known about the family perspective of the hospital stay. We interviewed families to understand their experiences during the newborn hospitalization for NAS and to improve family-centered care.

    METHODS A multidisciplinary team from 3 hospital units composed open-ended interview questions based on a literature review, clinical experience, and an internal iterative process. Trained investigators conducted semi-structured interviews with 20 families of newborns with NAS at hospital discharge. Interviews were recorded and transcribed verbatim. Two investigators independently analyzed each transcript, identified themes via an inductive qualitative approach, and reached a consensus on each code. The research team sorted the themes into broader domains through an iterative process that required consensus of 4 team members.

    RESULTS Five domains of family experience were identified: parents’ desire for education about the course and treatment of NAS; parents valuing their role in the care team; quality of interactions with staff (supportive versus judgmental) and communication regarding clinical course; transfers between units and inconsistencies among providers; and external factors such as addiction recovery and economic limitations.

    CONCLUSIONS Families face many challenges during newborn hospitalization for NAS. Addressing parental needs through improved perinatal education, increased involvement in the care team, consistent care and communication, and minimized transitions in care could improve the NAS hospital experience. The results of this qualitative study may allow for improvements in family-centered care of infants with NAS.

  14. Page 122
    Abstract
    Address correspondence to Philip Veliz, PhD, 1136 Lane Hall, 204 S State St, Ann Arbor, MI 48109. E-mail: ptveliz@umich.edu

    OBJECTIVES Previous research has found that adolescent athletes may be at increased risk of nonmedical prescription opioid use (NPOU) due to injuries. Although adolescent athletes are at an increased risk of engaging in NPOU, it has yet to be determined if they are also at greater risk for heroin use. The major purpose of this study was to examine both the trends in prevalence rates and patterns of initiation in lifetime NPOU and lifetime heroin use among adolescents who engage in sports and exercise.

    METHODS Eighteen cross-sections of eighth and 10th graders were used from the Monitoring the Future study. The sample consisted of 191 682 respondents who answered questions on past-year participation in sports and exercise, lifetime NPOU, lifetime heroin use, age of NPOU onset, and age of heroin onset.

    RESULTS The trends in NPOU and lifetime heroin use among adolescents who engage in sports and exercise has declined between 1997 and 2014. Logistic regression analyses found that adolescents who engage in sports and exercise had lower odds of reporting lifetime NPOU and heroin use compared with adolescents who did not engage in these activities during the past year. Analyses among lifetime heroin users found that adolescents who engage in sports and exercise had lower odds of initiating NPOU before heroin when compared with their peers who did not engage in these activities in the past year.

    CONCLUSIONS Daily participation in sports and exercise may serve as a protective factor with respect to NPOU and heroin use.

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